APPENDIX E DATA REPORTING REGULATIONS

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1 APPENDIX E DATA REPORTING REGULATIONS DATA REPORTING REGULATION Section 4602(e) of the Balanced Budget Act of 1997 authorizes the Secretary of the Department of Health and Human Services (HHS) to require that home health agencies (HHAs) submit any information that the Secretary considers necessary to develop a reliable case mix system for the purposes of implementing a prospective payment system for HHAs. To fulfill this mandate, CMS implemented a regulation requiring electronic reporting of OASIS data for Medicare and Medicaid patients to the State Agency (or other entity designated by CMS) as a condition of participation for HHAs. This rule provides guidelines for HHAs for the electronic transmission of the OASIS data as well as responsibilities of the State Agency or contractor in collecting and transmitting this information to CMS. Rules concerning the privacy of patient identifiable information generated by the OASIS were also set forth. The reporting regulation focuses on two Conditions of Participation (CoP) for the HHA at Code of Federal Regulations (CFR): CFR Title Reporting OASIS information and CFR Title Release of patient identifiable OASIS information, and CFR Title outlining the State Agency responsibilities for OASIS collection and database requirements. 42 CFR Condition of Participation: Reporting OASIS Information There are four standards in the Reporting OASIS Information CoP. In these standards, we address the following requirements: a (a) Standard: Encoding OASIS Data Once the comprehensive assessment has been completed and OASIS data collected, HHAs enter the OASIS information into the computer system, which we call encoding. All the time points of the OASIS assessments have a uniform time frame of thirty days from the date the assessment is completed (M0090 Date Assessment Completed) for encoding and submitting the data. Once the OASIS data are encoded (in software available from CMS or other software that conforms to the CMS standard electronic record layout, edit specifications, and data dictionary), the agency will review each assessment and edit it for transmission to the State Agency. During this preparation period, the HHA must run a software application that subjects each patient data set to the CMS edit specifications and makes it transmission-ready. The agency must correct any information that does not pass the CMS-specified edits (e.g., data is missing, incorrect, or inconsistent). Staff entering data may need to contact the qualified clinician who assessed the patient for assistance in making those corrections. The clinician s recall of the patient assessment and clinical notes, which document the assessment, are better at a point in time closer to the assessment activity than if the edits and corrections are delayed. HHAs have flexibility in the method used to encode their data. Data can be encoded directly by the skilled professional who conducts the assessment into a laptop or hand- December 2010 Appendix E-1

2 held computer, by a clerical staff member from a hard copy of the completed assessment, or by a data entry operator or service with whom the HHA may contract to enter the data. Any of these are acceptable methods of meeting the regulatory reporting requirements for OASIS. However, the HHA is ultimately responsible for meeting the reporting requirements as well as maintaining patient confidentiality. Non-clinical staff may not assess patients or complete assessment items; however, clerical staff or data entry operators may enter into the computer the OASIS data collected by the skilled professional. In entering the data, HHAs must comply with all requirements for safeguarding the confidentiality of protected health (patient-identifiable) information. Once the OASIS data are encoded, HHAs use their software to review and edit the data prior to transmission to the State Agency. When editing the data prior to transmission, it is important to remember that the edits include an electronic safety net to preclude the transmission of erroneous or inconsistent information and enforce the required formatting for the data set items. When transmitted, the patient assessment data are stabilized at the time point of the assessment, preventing the override of current assessment information with future or past information. b (b) Standard: Accuracy of Encoded OASIS Data The encoded OASIS data must accurately reflect the patient s status at the time the information is collected. Before transmission, the HHA must ensure that data items on its own clinical record match the encoded data that are sent to the State. We expect that once the qualified skilled professional completes the assessment, the HHA will develop a means to ensure that the OASIS data input into the computer and transmitted to the State Agency (or CMS contractor) exactly reflect the data collected by the skilled professional. Appendix B contains recommendations for conducting data quality audits on a routine basis and includes information from the original OASIS Implementation Manual (Chapter 12) (available at the following link (download Part I Chapters: Page ). In addition, the State survey process for HHAs may include review of OASIS data collected versus data encoded and transmitted to the State. c (c) Standard: Transmittal of OASIS Data CMS requires that the HHA electronically transmit the accurate, completed, and encoded OASIS data to the State Agency (or CMS contractor) within 30 days of the completion of the assessment (M0090 Date Assessment Completed). Data must be transmitted in a format that meets the requirements specified in the data format standard (i.e., conforming to the CMS standard electronic record layouts, edit specifications, and data dictionary). CMS believes that this time frame for transmitting the data will minimize the burden on the HHA associated with frequency of transmission, maintain uniform assessment reporting time frames, and maintain a clear reporting time frame that eliminates the variation of days in a month. Therefore, HHAs are free to develop schedules for transmitting the data that best suit their needs. HHAs must use CMS-specified electronic communications protocols to contact the State Agency or CMS contractor, transmit the export file, and receive validation information. HHAs required to submit OASIS data must do so using browser software to access the State system via the Medicare Data Communications Network, which provides a direct telephone connection for submission and interim reports. Once December 2010 Appendix E-2

3 transmitted, the State Agency or CMS contractor validates the information while the HHA remains on-line to ensure that some basic elements such as format and HHA information conform to CMS requirements. Once these file checks are completed, a message indicating whether the file has been accepted or rejected is sent back to the HHA s terminal and appears on its computer screen and is reported on the initial validation report displaying all Fatal File and Warning messages in relation to the submission file as a whole. If the submission passes the initial validation check, each individual record is then checked for errors or exceptions to the data specifications, and a Final Validation Report is generated. If the individual record is rejected, a message is sent to the HHA along with the rejected submission file for correction. A file or individual record may be rejected for a variety of reasons, (e.g., the provider identification name or number submitted may be incorrect, the number of records indicated in the trailer record does not match the actual number of records submitted). The HHA must make the corrections and resubmit the file to the State. HHAs must use a CMS-assigned branch identification number (where applicable) to identify branch-specific assessment information in a uniform fashion nationwide. This procedure finalized a process that began in January 2004, uniquely identifying every branch of every HHA certified to participate in the Medicare home health program. The system links the parent to the branch HHA and gives CMS the capability of monitoring the quality of care delivered by agencies down to the HHA branch level. For Medicare fee-for-service patients, the transmitted OASIS data also are utilized for billing. The HHA can submit a Request for Anticipated Payment (RAP) to their Regional Home Health Intermediary (RHHI) when all of the four following conditions are met: The OASIS assessment is complete and transmitted to the State, A physician s verbal orders for home care have been received and documented, A plan of care has been established and sent to the physician, and The first service visit under that plan has been delivered. An episode will be opened on Common Working File (CWF) with the receipt and processing of the RAP. RAPs, or in special cases claims, must be submitted for initial HH PPS episodes, subsequent HH PPS episodes, or in transfer situations to start a new HH PPS episode when another episode is already open at a different agency. HHAs should submit the RAP as soon as possible after care begins to assure they are established as the primary HHA for the beneficiary. d (d) Standard: Data Format To meet the data format requirements, HHAs may use software developed by CMS, the Home Assessment Validation Entry (HAVEN) system, or other vendor s software that conforms to CMS standardized electronic record formats, edit specifications, and data dictionaries. The HAVEN software can be used for several purposes. HHAs can use HAVEN to encode OASIS data, maintain agency and patient-specific OASIS information, and create export files to submit OASIS data. HAVEN provides comprehensive on-line help to users in encoding, editing, and transmitting these data sets. HAVEN can also be December 2010 Appendix E-3

4 used as a core program by HHAs and software vendors for developing their own software that supports OASIS reporting requirements, while also supporting or developing programs that meet other agency needs. Additionally, CMS maintains a toll-free help line to support this software product. The number for home health providers is , available 7AM to 7PM, Central Time. HAVEN alerts the individual who is encoding the data to use the correct screens for the specific type of assessment record required. HHAs using paper copies of assessment instruments must differentiate among the various subsets of OASIS data, i.e., specialized forms for particular assessment time points. HHAs are cautioned that the HAVEN system provides only the minimum requirements to encode data, transmit the data, and receive validation reports. CMS will support these functions and applications; however, we do not intend to provide any other applications related to care planning, financial information, durable medical equipment, medications, or personnel issues. Software developers are encouraged to use the HAVEN software to meet minimum requirements until they can ensure that their own software will accommodate CMS specifications and other applications useful for HHAs. If the HHA uses software other than HAVEN, it must conform to CMS standardized electronic record formats, edit specifications, and data dictionaries. The software must also include the various OASIS data sets. The required OASIS data set is available on our OASIS website located at click on "Data Set." HHAs can download the required OASIS data set for each data collection time point, i.e., start of care; resumption of care following an inpatient facility stay; follow-up; discharge (not to an inpatient facility); transfer to inpatient facility (with or without agency discharge); and death at home. In addition, CMS provides the HAVEN software on the same website, which can be downloaded at no charge to HHAs and used to report OASIS data. In addition to the software and the OASIS data set documentation available, this website includes the data specifications, data dictionaries, user s manual for the OASIS data set, HAVEN manual, HHA data submission manual, contact information for each state's OASIS Education Coordinator and OASIS Automation Coordinator, and access to OASIS Questions and Answers. Other educational materials for HHAs will be posted on the website. The site is intended to provide direct access for HHAs, State agencies, CMS contractors, software vendors, professional organizations, and consumers. Vendors and agencies are encourage to regularly review the website for information related to the computerization of OASIS and other CMS-related home health issues. CMS will continue to promote processes for ensuring accuracy in the software. In the future, as OASIS is revised, HHAs will be directed to the CMS OASIS website for the current version of the OASIS data set. HHAs may also obtain hard copies from the National Technical Information Service at CFR Condition of Participation: Release of Patient Identifiable OASIS Information The HHA or an agent acting on behalf of the HHA must ensure that all protected health (patientidentifiable) information in the clinical record, including OASIS data, remains confidential and is not released to the public. The data, whether in hard copy or in electronic format, must be secured and controlled. In addition to the provisions of this Condition of Participation, all HHAs must adhere to the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to ensure patient confidentiality and the security of patient information. (Further information on these requirements is provided on-line at December 2010 Appendix E-4

5 CMS specifies that the HHA who chooses to secure the services of an agent to complete the OASIS regulatory reporting requirements must secure a written contract between the HHA and the agent to not use or disclose the information. The agent may only release data to the extent the HHA itself is permitted to do so. It is believed that this CoP will act as a safeguard against the unauthorized use of a patient s clinical record information, regardless of the form or storage method. State Agency Responsibilities for OASIS Collection and Database Requirements Under section 1891(b) of the Social Security Act, the Secretary of the Department of Health and Human Services must assure that processes are in place to protect the health and safety of individuals under the care of an HHA and to promote the effective and efficient use of public monies. Section 1864 of the Act authorizes the use of State health agencies to determine a provider s compliance with the CoPs. State responsibilities in ensuring compliance with the CoPs are set forth at Part 488, Survey, Certification, and Enforcement Procedures. State Agency OASIS collection and database responsibilities have been added to the other State responsibilities at 42 CFR 488. This section provides that the overall responsibility for fulfilling requirements to operate the OASIS system rests with the State Agency or other entity under direct contract with CMS. The State may enter into an agreement with the State Medicaid agency, another State component, or a private contractor to perform day-to-day operations of the system, or CMS may directly contract with an authorized entity. These CMS contractors perform the duties on behalf of CMS or the State Agency. While these entities may actually perform all OASIS-related functions, the ultimate responsibility of the OASIS program rests with the State Agency or authorized entity under contract directly to CMS. If the standard State system is operated by an entity other than the State Agency, the State must ensure that it has suitable access to this system to fully support all OASIS-driven functions required of the State Agency (for example, outcome-based quality improvement reports and survey specific data). The regulation specifies State Agency and CMS contractor responsibilities with regard to the OASIS system. As part of State Agency survey responsibilities, the State Agency or other entity designated by CMS has overall responsibility for fulfilling the following requirements for operating the OASIS system. The State Agency or other entity designated by CMS must establish and maintain an OASIS database on the standard system developed or approved by CMS to collect, store, and analyze data; conduct basic system management activities including hardware and software maintenance, system back-up, and database monitoring; and analyze and report OASIS data to CMS. The State Agency must edit the data on receipt from the HHA, as specified by CMS, and ensure that the HHA resolves errors within the limits specified by CMS. At least monthly, all edited OASIS records received during that period must be made available for retrieval by CMS. The State Agency must ensure that access to data is restricted (except for the transmission of data and reports to CMS) to the State Agency component that conducts surveys for purposes related to this function, and to other entities if authorized by CMS. The State Agency must ensure that patient identifiable OASIS data are released only to the extent permitted under the Privacy Act of 1974 and the Administrative Simplification provision of the HIPAA Act of The System of Records supports the HHA/OASIS database. The State Agency provides training and technical support for HHAs. The State Agency or other entity designated by CMS must instruct each HHA on the administration of and integration of the December 2010 Appendix E-5

6 OASIS data set into the facility s own record keeping system; instruct each HHA on the use of software to encode and transmit OASIS data to the State; monitor each HHA s ability to transmit OASIS data; provide ongoing technical assistance and general support to HHAs in implementing the OASIS reporting requirements specified in the Conditions of Participation for HHAs; and carry out any other functions as designated by CMS necessary to maintain OASIS data on the standard State system. Privacy Act System of Records Notice The Privacy Act System of Records (SOR) Notice was first published in the Federal Register, Vol. 64, No. 117, June 18, 1999, and was updated in the Vol. 66, No. 248 Federal Register, published on December 27, 2001 and Vol. 72, No. 218 Federal Register, published November 13, The original notice describes the purpose of the new SOR (a national database) and identifies the statutory authority for creation and maintenance of the system and appropriate routine uses of the data. Clinical assessment information for all Medicare or Medicaid patients receiving the services of a Medicare- or Medicaid-approved HHA except for those receiving HHA services for pre- and post-partum conditions, patients less than 18 years of age, and patients receiving exclusively personal care or non-health care services (i.e., chore or homemaker services) is included in the System of Records (SOR). The assessment information contained in the SOR are OASIS data. These data are obtained through a patient assessment that SOR conducted by a registered nurse or qualified therapist. To determine the type of care needed by a patient, HHAs perform an assessment of each patient's physical and emotional status. HHAs will continue to do these assessments, but now they will report a portion of that assessment to CMS to perform several critical functions, such as calculating the appropriate amount to pay for home health services, and to ensure that HHAs are providing the highest quality of care for the entire agency and for each individual patient. Home health patients are one of the most vulnerable populations because services are provided in the home where it is difficult to oversee the quality of services provided. OASIS data allow CMS to measure how well HHAs care for their patients through the development of performance profiles for each agency. Consistent with the HIPAA Privacy and Security Rules, the Privacy Act permits CMS to disclose information without an individual's consent if the information is to be used for a purpose that is compatible with the stated purpose(s) for which the information was collected. This disclosure is known as "routine use." Several routine use disclosures have been identified for OASIS data. These data may be disclosed only to: The Department of Justice, court, or adjudicatory body when CMS is involved in litigation or when CMS' policies or operations could be affected by the outcome of the litigation. A third party with whom CMS has contracted to assist in accomplishing CMS functions relating to purposes of the System of Records. Another Federal or State Agency, agency of a State Government, or established by State law, for purposes of evaluating and monitoring the quality of home health care and contributing to the accuracy of CMS' health insurance operations. A Quality Improvement Organization (QIO), to assist in performing specific functions relating to assessing and improving HHA quality of care. December 2010 Appendix E-6

7 An individual or organization for research, evaluation, or epidemiological activities related to health. A member of Congress or a Congressional staff member in response to an inquiry of the Congressional Office made at the written request of the constituent about whom the record is maintained. The December 27, 2001, Federal Register notice added a seventh use disclosure: National accrediting organizations with approval for deeming authority for Medicare requirements for home health services, allowing these organizations to target potential or identified problems during the accreditation review process. The June 18, 1999 Federal Register notice also identified the specific safeguards in place to ensure confidentiality of patient-level data. Please refer to this announcement for details. Deficit Reduction Act of 2005 Requirement for Reporting Quality Data and Public Reporting for Quality Measures In 2005, the Deficit Reduction Act (DRA) Section 5201(c) (2) was passed by Congress and added section 1895(b) (3) (ii) (V) to the Social Security Act requiring each HHA to submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality for 2007 and each subsequent year. Section 5201 (c)(v) requires a payment adjustment if an HHA does not submit data for the reporting year, "the home health market basket percentage increase applicable for such year shall be reduced by 2 percentage points. The two percent reduction would begin to apply to annual payment updates beginning on January 2007 and each year thereafter. For calendar year (CY) 2010, the data will be will based on OASIS submissions from 7/1/2008 through 6/30/2009. The law also requires the Secretary to establish procedures for making data submitted available to the public and ensures the HHA has the opportunity to review the data prior to the data being made public. HHAs currently have pre-publication access to their own agency's quality data (which the contractor updates periodically). CMS proposes to continue this process, to enable each agency to know how it is performing before public posting of data on the Home Health Compare website. CMS also publishes an annual Preview Report in the fall of each year (available to home health agencies on the Casper Reporting system and posted the QTSO memorandum in the OASIS State Welcome Page in their folders to advise agencies of the preview reports and how to access them). See the Reporting Home Health Quality Data for Annual Payment Update website at the following link: and refer to QTSO Memorandum , published November 17, 2006 in the Downloads section of that website. Also see Pay for Reporting Implementation Links and Downloads for the original DRA, Rule and Press Release. The Secretary of the Department of HHS has determined that the OASIS information collection best meets the requirements of this statutory mandate. Continuing to use the OASIS instrument ensures that providers will not have an additional burden of reporting through a separate mechanism and that the costs associated with the development and testing of a new reporting mechanism can be avoided. December 2010 Appendix E-7

8 Therefore, OASIS assessment episodes submitted by home health agencies to CMS for Condition of Participation compliance for dates of service beginning July 1 and ending June 30 of each year will count as meeting the reporting requirement for CY as listed in the rules for annual payment update. (This reporting time period would allow 12 full months of data and would provide CMS the time necessary to analyze and make any necessary payment adjustments.) CMS proposes to reconcile the OASIS submissions with claims data every year in order to verify full compliance with the quality reporting. HHAs that meet the reporting requirements would be eligible for the full home health market basket percentage increase. CMS has proposed that HHAs certified on or after May 1 each year for payments to be made in the next calendar year to be excluded from the quality reporting requirement data for use in that CY, as data submission and analysis would not be possible for an agency certified this late in the reporting time period. At the soonest time possible after obtaining the CMS Certification Number (CCN), reporting is mandated. We note these exclusions only affect quality reporting requirements and do not affect the agency's OASIS reporting responsibilities under the CoP submission requirement. The data elements will not require additional reporting or burden to HHAs. The reporting requirement is to transmit during the reporting year (between 7/1/2008 and 6/30/2009) to get complete payment the following payment year, If a new HHA is approved for operation between 5/1/2009 and 6/30/2009, they do not have to meet the reporting (transmission) requirement by 6/30/2009 because their paperwork would not be completed in time for them to transmit by 6/30/2009 (would not have tie-in notice for CMS Certification Number (CCN) and password to transmit to the OASIS system). They would not be subject to the market basket decrease in the CY (calendar year) that follows, Additionally, section 1895(b) (3) (B) (v) (II) of the Act provides the Secretary of the Department of HHS with the discretion to submit appropriate health care quality data in form, manner, and a specified time frame. Such measures would be evidence-based, clearly linked to improved outcomes, and able to be reliably captured with the least burden to the provider. The OASIS Version C has undergone final revisions based on OMB public comment period and the NQF steering committee process. The implementation of OASIS Version C is anticipated to begin collection in 2010 with HH Compare display of new and refined measures in 12/2010 for a 2011 Pay for Reporting (P4R) impact. There will be a transition of measure requirements as the data elements and quality measures change. CMS will indicate in rulemaking the transition of measures it plans to post on Home Health Compare. Some measures may continue to be reported, while others will be new and refined, and others retired. Measure priorities are determined with each annual payment update. December 2010 Appendix E-8